Sample Appeal Letter Template printable pdf download

[Date]

[Payer n ame]

ATTN: A PPEALS

[Payer c ontact n ame]

[Payer a

ddress]

Patient:

[ Patient’s f irst a nd l ast n

ame]

Subscriber I D#:

[ Insurance I D # ]

Subscriber G roup # :

[ Insurance g roup #

]

Re: C OTELLIC® ( cobimetinib) t ablets

Dates o f S ervice:

[ Include a ll d enied d ates o f s

ervice]

Dear A ppeals R eviewer:

I a m w riting t o r equest

[

appeal/redetermination/reconsideration] o f t he a bove d enial(s) o f

COTELLIC® ( cobimetinib) t ablets f or m y p atient

[ patient n

ame]. I u nderstand f rom y our

denial l etter t hat t he d enials w ere b ased o n

[ denial r

eason]. I w ould l ike t o a ddress

[ that

reason/those r

easons] n ow. I w ould a ppreciate a p rompt r eview o f t he e nclosed

information d emonstrating m edical n ecessity a nd c overage f or C OTELLIC.

Patient’s C linical H istory

[Patient’s n

ame] i s a

[

age] y ear o ld

[

male/female] w ho w as d iagnosed o n

[

date] w ith s tage

[IIIC/ I

V] m etastatic m elanoma. T reatment o ptions f or p atients w ith m etastatic m elanoma

are l

imited. [

He/She] u nderwent

[ describe t reatment t o d

ate].

[Include d iagnosis a nd d ates]

•

[Past t reatments]

•

[Test r esults t hat i ndicate f ailure o f p ast t reatment]

•

[Extenuating c ircumstances t hat w ould p reclude a lternatives t o C OTELLIC]

•

[Social & f amily i nformation]

•

[REMINDER: I f a p ayer h as a p ublished p olicy, i nclude h ere]

[REMINDER: I f s tate s tatute e xists, i nclude h ere]

Treatment P lan

On 1 1/10/2015, t he F DA a pproved t he u se o f C OTELLIC f or t he t reatment o f p atients w ith

unresectable o r m etastatic m elanoma w ith B RAF V 600E o r V 600K m utation, i n c ombination

with v emurafenib.

[Include p lan o f t reatment ( dosage, l ength o f t reatment), F DA A pproval L etter, r elevant

journal a rticles, c linical s tudies, a nd c linical p ractice g uidelines t hat s upport t he u se o f

COTELLIC. C onsider m entioning e xperts i n t he f ield w ho a lso s upport t he t reatment.]

Summary

In s ummary, I a m r equesting

[ appeal/ r edetermination/ r

econsideration] o f t he d enial(s) o f

COTELLIC t herapy f or m y p atient,

[ Patient N

ame].

[ He/ S

he] w as d iagnosed w ith

unresectable s tage

[ IIIC/ I

V] m elanoma w hich i s p ositive f or t he B RAF V 600 m utation; a

life-‐threatening m elanoma w ith f ew t reatment o ptions. I a m r equesting t hat y ou r econsider

coverage b ased o n t he i nformation a bove. I a m r eadily a vailable a t m y o ffice p hone

[ MD

ACS/030915/0032

Sample Appeal Letter Template

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